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Home My WebLink About16655 (39)EDUL110,14 BaK i CITY OF DIAMOND BAR DEpA.RTjvmN ` OF CO M17i*THY & DEVELOPMENT SERVICES 21925 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS APN L T Ti;Aj OWNER f+ ADDRESS CITY ZIP TEL. APPLICANT TEL, CONTRACT R ADDRESS CITY ZIP TEL.�7Y� ARC H/ENG/ DESIGNER ADDRESS CITY ZIP __ TEL. _ OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAWFORTHEFCLLOWING EASON(SEC.7031.5 BUSINESSAN'D PROFESSIONS CODE: ANYCITY OR COUNTY WHICH REQUIRESAPER rTT0 CoN5TRUCT,AL7ER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- TURE, PRIOR TO ITS ISSUANCE, LSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 DF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HEOR HEISEXEMPTTHEREFRCM AND THE BASIS FORTHEALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031 A BYANYAPPLICANT FOR A PERMIT SUBJECTS 7HE APPLICANT TO A CIVIL PENALTY OF NOT MORE T AN FIVE HUNDRED DOLLARS ❑ LASOWNEROFTHEPROP PTV, OR MY EMPLOYEES WITH WA3ESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE ST UCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044, BUSI- NESS AND PROFESSIONS CODE: HE CONTRACTORS LICENSE LAW DOES NOT APPLY i0 AN OWNER OF PROPERTY WHO BUILDS ORIMPR VE$THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGHHISORHER OWN EMPL TEES, PROVIDEOTHIA SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFEREDFORSALEAF,HOWEVER, HERUILOMGORIMPROVEMENTISSOLDWtTHINONEYEAROFCOMPLE- TION, THE OWNER -BUILDER WILL AVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FORTHE PURPOSE OF ALE).. ❑ I, AS OWNER OFTHEPRO RT', AM EXCLUSIVELY CONTRACTINGWITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (S C. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- DENSELAWDOESNOTAPPLYTO N OWNER UFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PRO IWITH ACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. 1 P.C. FOR THIS REASON DATE OWNER I LICENSED CONTRACTORS DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7600) OF DIVISION 3Or THE BUSINESSAND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE ANO EFFECT. LICENSE CLAS + LIC. NO. DATE BI CONTRACTOR L✓'r �'�" 7 i WORKERS'COMPENSATION DECLARATION ) I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF -INSURE FOR WORKERS' COMPENSATION, AS I DED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE F THE WORK FOR WHICr THIS PERMIT IS ISSUED. ] I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODEI FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'C MPE ATION INSU ECARRIER OPOLICYNUh9BERARE: CARRIER___ --- v POLICY NUMBER �.�—vim (THIS SECTION NEED NOT BECOMPLETED OF THE PERMIT IS FOR ONE HUNDREDUOLLARS ($100) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY FIFRSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE 7 WORKERS' COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT iO THE WORKEFS'COh1PENSATION PROVI&ONS OF SEC ON 37000FT LABOR COD ,1 ALL FD WITH COMPLY VATH THOS OV1SiON8. J DATE: ✓ AE�PLICANT. u '] WARNING: FAILURE TO SECURE WbRKEAS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE J SUBJECT AN EMPLO'fERTO CRIMiAL PENALTIES AND CIVIL FINESUP TO ONE HUNDRED THOUSAND L DOLLARS ($100,OOW), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 370E OF THE LABOR GORE, INTEREST, AND ATTORNEYS FEES. i CONSTRUCTION LENDING AGENCY L (HEREBYAFFIRM UNDER PENALT�OF PERJUR FH THERE lS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE Wi DR �',F R IC HIS PERA7IT IS ISSUED (SEC. 3097, CIV C.). A7 L LENDER'SNAME ---- LENDER'S ADDRESS (CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THEABOVE IN%ORMATION IS CORRECT. AGREETO COMPLYWITH ALL CITY AND'COUNTY ORDINANCES ANDSTATE LAWS RELATING TO BUILDING i CONSTRUCTION, AND HERFBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY70 ENTER UPON THE ABOVE -MENTIONED PROPERTY FC R INSPECTION PURPOSES. t PERMITTE" AME (PRI T :1] /V .! rn SfQ17ATUREOPPERMITTEE DATE g PRESS FIRMLY APPLICATION PERMIT P/C DATE NUMBER # n ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW REAR j SIDE/SIDE STREET RW :1 SIDE C PROPOSED USE NO. DWEL NO, NO. UNITS STORIES _ 1__ BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport co LLLI Patio/Deck LL PooVSpa ZRe -Roof ® Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE U r µJS J LD C!7 Z � G CL U Z Q 2 LU CONSTRUCTION PLAN REVIEW ELECTRIC -- PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMiP ( ENERGY P/C _ e ENERGY PERMIT -- RETENTION FEE: _ F PRE-ALT FEE: TOTAL FEES t✓ - COMMENTS � 7 RECPT. NC. PAID BY VALIDATION WHITE —Department Copy, YELLOW —Finance Copy, PINK—ASSeSSOr copy, UVLUClNY VU—rl IV VV'Hy, FAT LL. i':d i , 3'.f' F k y ... .: Y: `.w Y u. a